Guest Column: Heartburn can be a heartache

Tuesday

Nov 6, 2012 at 2:00 PMNov 6, 2012 at 3:00 PM

Gastroesophageal reflux disease or GERD is a common problem effecting 25 to 35 percent of Americans at some point in their lives. It presents with symptoms of heartburn, regurgitation, and difficulty swallowing. For most sufferers, the symptoms can be as bad or worse as those of menopause, peptic ulcers, or angina.

by William Culbert

Gastroesophageal reflux disease or GERD is a common problem effecting 25 to 35 percent of Americans at some point in their lives. It presents with symptoms of heartburn, regurgitation, and difficulty swallowing. For most sufferers, the symptoms can be as bad or worse as those of menopause, peptic ulcers, or angina.

Reflux, in itself, is a normal physiological process that occurs up to once an hour, but several things can cause it to become a chronic and relapsing illness. Normally, stomach acid is cleared rapidly from the lower esophagus by saliva and gut motility, but GERD sufferers may have defects in these mechanisms.

They may have an intrinsic problem with the lower esophageal valve and the diaphragm that work together to control reflux. They may have some low production of acid-neutralizing bicarbonate by glands in the lower esophagus. About 60 percent of those with GERD will have reflux acids from the gallbladder, as well as from the stomach. The contribution of this to symptoms is unclear. Obesity with increased fat around the abdominal organs makes a significant contribution. A high-fat diet contributes to a delay in gastric emptying and increases the risk of GERD.

The natural course of the disease will leave about three quarters of sufferers with diminishing symptoms, but about two thirds of them will still show objective signs of disease. Untreated, GERD can cause inflammation of the lower esophagus, ulcerations, strictures, or even pre-cancerous changes called Barrett's esophagus.

Conservative measures should always be tried first. Small, frequent meals can reduce symptoms. A food diary is important to identify offending foods. Weight loss and a low-fat diet are a given. Exercise, in general, helps to move GI contents downward stimulating normal motility. Maintaining the integrity of the lower-esophageal sphincter can be helped by avoidance of bending at the waist. Avoid sphincter relaxers like alcohol, caffeine, smoking, and peppermint. Prop the head of the bed up six inches. Do not prop up by adding pillows. It will worsen the condition because it promotes bending at the waist compromising sphincter control. Avoid eating within two hours of bedtime or eat a light, high-carbohydrate snack such as some flake cereal with a little skim milk.

The diagnosis of GERD is usually accomplished by observing the response to a 14-day trial of a class of drug called "proton pump inhibitors" or PPIs. A few common trade names include Prilosec, Prevacid, and Nexium. These drugs close down the acid-producing cells of the stomach for a day, dramatically controlling symptoms and start the healing of esophageal erosions. This method has been found to be as effective for diagnosis as electronically monitoring stomach acidity.

Symptoms that may indicate more serious long-term problems would include chest pain, painful swallowing or progressively more difficult swallowing, weight loss, or a stricture that might make it difficult for food to pass from the esophagus into the stomach. These symptoms or unresponsiveness to PPIs would warrant a consult with a gastroenterologist and direct visualization by endoscopy. Of course, systemic symptoms such as fever, chilling, vomiting, anorexia, rapidly-progressive abdominal pain or rigidity could be indicators of acute conditions such as appendicitis or diverticulitis and should result in an immediate visit with a physician.

PPIs have been transformative drugs for healing gastric or duodenal ulcers and they work well for GERD symptoms with minimal short-term side effects. This combination has, unfortunately lead to an epidemic of inappropriate usage with serious long-term consequences if taken more than 10 to 12 months. It is worth taking some time here to discuss the implications.

Because PPIs stop stomach acid instead of just decreasing its production like over-the-counter drugs like Zantac or Pepcid, they can seriously limit the absorption of essential minerals like iron, calcium, and magnesium. Over time, this can lead to anemia, osteoporosis, and heart arrythmias. The acid environment of the stomach is necessary for cleaving B-12 from the protein it is bound to in food, so loss of B-12 absorption is promoted by PPIs. This happens in another way as well.

The stomach cells that produce acid also produce a chemical called intrinsic factor necessary for vitamin B-12 absorption. Long-term use of PPIs can significantly decrease B-12 absorption leading to several subtle problems like short-term memory loss, instability with walking, and neurological problems such as impaired cognition. Loss of these stomach cells with age leaves between 3 and 12 percent of all elderly in the U.S. with frank B-12 deficiency as seen with low blood B-12 levels, but as many as one in four older Americans with normal levels have some element of B-12 depletion. A more sensitive indicator is an elevated blood level of methylmalonic acid, but this is a more expensive test costing around $200. One milligram or 1,000 micrograms daily of oral B-12 can bypass some of the mechanism responsible for this loss. It should generally be taken as part of a B complex or multi-vitamin because of its interaction with other B vitamins, especially folic acid.

Over time, total suppression of stomach acid may lead to colonization of the upper GI tract with bacteria that significantly increase the risk of aspiration pneumonia. Stomach acid is also a first-line defense against GI infections.

If a PPI is taken for more than about a month, there can be a rebound effect when trying to discontinue its use. It should be taken with a drug like Zantac for several days and then delay the PPI pill each day until it can be taken occasionally. You should always discuss this with your doctor to see if you are an appropriate candidate for withdrawing this type of medicine.

As with any important medical innovation, the potential for great benefit must be weighed against the risks on an individual basis. Never forget that the conservative measures of weight loss, exercise, and a healthier diet seem to impact almost all aspects of health. GERD is no exception.

Physician William Culbert lives in Oak Ridge and has a practice in Clinton.